Provider Demographics
NPI:1972975886
Name:MEDICAL OUTREACH SERVICES OF MADISON PC
Entity Type:Organization
Organization Name:MEDICAL OUTREACH SERVICES OF MADISON PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:P
Authorized Official - Prefix:
Authorized Official - First Name:MIGUEL
Authorized Official - Middle Name:EDUARDO
Authorized Official - Last Name:COSSIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:706-342-9664
Mailing Address - Street 1:1075 S MAIN ST
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-2033
Mailing Address - Country:US
Mailing Address - Phone:706-342-9664
Mailing Address - Fax:
Practice Address - Street 1:1075 S MAIN ST
Practice Address - Street 2:SUITE 400
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-2033
Practice Address - Country:US
Practice Address - Phone:706-342-9664
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-30
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000289517AMedicaid
GAGRP7517Medicare UPIN